Difference between revisions of "Pancreas transplant"

Pancreas transplant
Anesthesia type	General
Airway	ETT
Lines and access	2-3 PIV, 16-18 G, Arterial Line
Monitors	Standard, 5 lead ECG
	Primary anesthetic considerations
Preoperative	Glucose and Hemoglobin
Intraoperative	Labile Glycemia -insulin and glucose may be needed in the same patient. Heparin should be prepared and may be sued before clamping of the iliac A or V before pancreatic anastomosis. Intraop immunosuppression should be running before Thymoglobulin or Simulect and prior to reperfusion.
Postoperative
	Article quality
Editor rating	Unrated
User likes	0

VisualWikitext

Latest revision as of 21:24, 5 January 2023

Pancreas transplantation is performed in one of the following three settings (in decreasing order of frequency): Simultaneous pancreas and kidney transplant (SPK) Pancreas after kidney transplant (PAK) Pancreas transplant alone (PTA).

Overview

Preoperative management

Patient evaluation

The recipients are patients with longstanding type 1 diabetes(juvenile onset) and therefore have issues related to long term glucose intolerance.


System	Considerations
Airway	Incidence of difficult intubation is somewhat increased in this patient population due to limited mobility of the cervical spine or temporomandibular joint.
Neurologic	autonomic nervous system dysfunction, systemic and peripheral neuropathy
Cardiovascular	CAD is common in this population
Gastrointestinal	gastroparesis
Renal	Renal insufficiency
Endocrine	Insulin dependence is likely in this population. Favorable peri-operative glycemic control and pre-operative glucose assessment is necessary. Pre-operative NPO status requires insulin adjustments.
Other

Labs and studies

CBC
CMP

Operating room setup

Prepare arterial line
Have heparin in the room
May need steroid and anti-thymocyte globulin and/or Basiliximab prepared
Discuss Abx with surgical team: Cefazolin 2 grams and Flagyl 500 mg IV, or Clindamycin IV 600 mg and Ciprofloxacin 400 mg IV (if penicillin allergy)

Patient preparation and premedication

Consider midazolam and Tylenol

Regional and neuraxial techniques

Epidural or CSE may be used for postop pain management

Intraoperative management

Monitoring and access

Arterial line for blood pressure monitoring and frequent lab draws
Many patients also have ESRD - IVs and arterial lines should avoid the side of AV fistula if present
Nasogastric tube should be placed, secured, and position confirmed, prior to emergence

Positioning

Supine-the operative approach is intra-abdominal via a midline laparotomy

Maintenance and surgical considerations

Normal blood pressure is important for pancreas reperfusion and additional fluid and/or vasopressors may be needed at the time of organ reperfusion
Significant bleeding from the pancreas graft may occur following reperfusion-It is not uncommon for patients to require transfusion with blood products (generally not more than 2 units).
At case conclusion, the surgical team may request a low dose heparin infusion (300-400 units/hr) for vascular patency of the graft, provided hemostasis is adequate.
Glucose management may vary from an insulin infusion to glucose infusion in the same patient

Emergence

A Nasogastric tube should be placed, secured, and position confirmed, prior to emergence
Most patients are candidates for extubation

Postoperative management

Disposition

A surgical ICU bed postoperatively is typically required

Pain management

Potential complications

Significant bleeding from the pancreas graft may occur following reperfusion-It is not uncommon for patients to require transfusion with blood products (generally not more than 2 units).
hypoglycemia

Procedure variants


	Variant 1	Variant 2
Unique considerations
Indications
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

Top contributors: Tony Wang and Imelda Muller

@@ Line 1: / Line 1: @@
 {{Infobox surgical procedure
-| anesthesia_type =
+| anesthesia_type = General
-| airway =
+| airway = ETT
-| lines_access =
+| lines_access = 2-3 PIV, 16-18 G, Arterial Line
-| monitors =
+| monitors = Standard, 5 lead ECG
-| considerations_preoperative =
+| considerations_preoperative = Glucose and Hemoglobin
-| considerations_intraoperative =
+| considerations_intraoperative = Labile Glycemia -insulin and glucose may be needed in the same patient. Heparin should be prepared and may be sued before clamping of the iliac A or V before pancreatic anastomosis.  Intraop immunosuppression should be running before Thymoglobulin or Simulect and prior to reperfusion.
 | considerations_postoperative =
 }}
-Provide a brief summary here.
+Pancreas transplantation is performed in one of the following three settings (in decreasing order of frequency): Simultaneous pancreas and kidney transplant (SPK) Pancreas after kidney transplant (PAK) Pancreas transplant alone (PTA).
 == Overview ==
-=== Indications<!-- List and/or describe the indications for this surgical procedure. --> ===
-=== Surgical procedure<!-- Briefly describe the major steps of this surgical procedure. --> ===
 == Preoperative management ==
-=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===
+=== Patient evaluation ===
+The recipients are patients with longstanding type 1 diabetes(juvenile onset) and therefore have issues related to long term glucose intolerance.
 {| class="wikitable"
 |+
@@ Line 26: / Line 23: @@
 |-
 |Airway
-|
+|Incidence of difficult intubation is somewhat increased in this patient population due to limited mobility of the cervical spine or temporomandibular joint.
 |-
 |Neurologic
-|
+|autonomic nervous system dysfunction, systemic and peripheral neuropathy
 |-
 |Cardiovascular
-|
+|CAD is common in this population
-|-
-|Pulmonary
-|
 |-
 |Gastrointestinal
-|
+|gastroparesis
-|-
-|Hematologic
-|
 |-
 |Renal
-|
+|Renal insufficiency
 |-
 |Endocrine
-|
+|Insulin dependence is likely in this population. Favorable peri-operative glycemic control and pre-operative glucose assessment is necessary. Pre-operative NPO status requires insulin adjustments.
 |-
 |Other
@@ Line 53: / Line 44: @@
 |}
-=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===
+=== Labs and studies ===
+* CBC
+* CMP
+=== Operating room setup ===
+* Prepare arterial line
+* Have heparin in the room
+* May need steroid and anti-thymocyte globulin and/or Basiliximab prepared
+*Discuss Abx with surgical team: Cefazolin 2 grams and Flagyl 500 mg IV, or Clindamycin IV 600 mg and Ciprofloxacin 400 mg IV (if penicillin allergy)
+=== Patient preparation and premedication ===
-=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
+* Consider midazolam and Tylenol
-=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
+=== Regional and neuraxial techniques ===
-=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
+* Epidural or CSE may be used for postop pain management
 == Intraoperative management ==
-=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
+=== Monitoring and access ===
+* Arterial line for blood pressure monitoring and frequent lab draws
+* Many patients also have ESRD - IVs and arterial lines should avoid the side of AV fistula if present
+* Nasogastric tube should be placed, secured, and position confirmed, prior to emergence
-=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
+=== Positioning ===
-=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
+* Supine-the operative approach is intra-abdominal via a midline laparotomy
-=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
+=== Maintenance and surgical considerations ===
-=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
+* Normal blood pressure is important for pancreas reperfusion and additional fluid and/or vasopressors may be needed at the time of organ reperfusion
+* Significant bleeding from the pancreas graft may occur following reperfusion-It is not uncommon for patients to require transfusion with blood products (generally not more than 2 units).
+* At case conclusion, the surgical team may request a low dose heparin infusion (300-400 units/hr) for vascular patency of the graft, provided hemostasis is adequate.
+* Glucose management may vary from an insulin infusion to glucose infusion in the same patient
+=== Emergence ===
+* A Nasogastric tube should be placed, secured, and position confirmed, prior to emergence
+* Most patients are candidates for extubation
 == Postoperative management ==
-=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
+=== Disposition ===
+* A surgical ICU bed postoperatively is typically required
 === Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
-=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
+=== Potential complications ===
+* Significant bleeding from the pancreas graft may occur following reperfusion-It is not uncommon for patients to require transfusion with blood products (generally not more than 2 units).
+* hypoglycemia
 == Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==